Provider Demographics
NPI:1609946151
Name:REDDY, PRODDUTUR VITTAL (MD)
Entity Type:Individual
Prefix:
First Name:PRODDUTUR
Middle Name:VITTAL
Last Name:REDDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:P
Other - Middle Name:V
Other - Last Name:REDDY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:925 NW 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1809
Mailing Address - Country:US
Mailing Address - Phone:580-223-0011
Mailing Address - Fax:
Practice Address - Street 1:925 NW 15TH AVE
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1809
Practice Address - Country:US
Practice Address - Phone:580-223-0011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11121207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100181280AMedicaid
OK100181280AMedicaid